Anorectal disease Flashcards
Compare internal vs. external hemorrhoids based on location
Internal - proximal to **Dentate line (sup hemorrhoidal veins and painless)
External - distal to Dentate line (inf hemorrhoidal vein and painful)
What are some typical causes of hemorrhoids?
Increased venous pressure from:
Straining Constipation Prolonged sitting Pregs Obesity Low fiber
Differentiate between epithelium of internal and external hemorrhoids. Why does this matter?
Internal - COLUMNAR epithelium can deposit mucous on skin and cause ITCHING
External - squamous epithelium w/ pain receptors
How will a typical hemorrhoid patient present?
C/o bright* red* rectal bleeding. Streaks on the TP or dripping into the toilet.
May also say they have Perianal itching, Mucoid discharge w/ stool, and pain w/ **EXTERNAL hemm.
Prolapse of internal hemorrhoid may result in what?
Leakage of rectal contents.
Patients over-clean and irritate the perineum…. fecal material on denuded skin
What results in prolonged contact of fecal material with perianal skin and local irritation? **Not secondary to cleaning
Skin tags from external hemorrhoids (difficult to clean)
What are the pearls of a hemorrhoid physical exam?
EXT hemorrhoids may be VISIBLE
INTERNAL may prolapse with VALSALVA
You have to:
Look for Tags, Fissures, Fistulas, Condyloma, Dermatitis
Do a DRE
Do an ANOSCOPIC exam if you are unsure
Describe the internal hemorrhoids grading classification.
Graded on degree of PROLAPSE
- only bleeding
- Prolapse when poop, back in on own
- Prolapse when poop, must be pushed back
- Incarcerated prolapse, cant go back
How will a thrombosed hemorrhoid patient present? What needs to happen for this person?
UNRELENTING PAIN due to clot (if external **most common)
Internal can also thrombose
Pt needs SURGICAL evacuation of clot
Describe general treatment of hemorrhoids (non pharm)
High FIBER
Increase FLUID
Wet WIPES (hygiene and pain relief)
Describe Medical treatment of hemorrhoids.
What if they are Internal and require further tx?
Topical Astringent (Witch hazel/tucks) Topical Hydrocortisone (cream or foam) Topical anesthetics (Pramoxine or Dibucaine) Hydrocortisone suppositories (Prep H)
If further tx needed and internal:
Band ligation
Sclerotherapy
Electrocoagulation
When is surgical treatment required for hemorrhoids? Whats the risk?
Only if meds fail or….
Chronic severe bleeding is present
May cause fecal incontinence***
Define an anal fissure.
A TEAR in the anoderm DISTAL to the dentate line.
Why do people get anal fissures?
Most common cause = Trauma to anal canal during defecation.
Strain, constipated, High INTERNAL sphincter tone
An anal fissure can be acute or chronic. How does a chronic fissure develop?
Spasm of the internal sphincter –> impaired healing
Where are anal fissures most likely to develop? If they don’t develop here, what should we think about?
Posterior midline 75%. Anterior 25%
If not midline, think:
Crohn, HIV, TB, Syphilis, Carcinoma, Trauma
How will an anal fissure patient present?
Acute onset of SEVERE, TEARING pain during defecation… If chronic, LESS PAIN.
Mild HEMATOCHEZIA - BRB on the TP
CONSTIPATION - self induced due to fear
What will we find during PE of an anal fissure PT
anal fissure - *small tear in epithelium
Spread buttocks = PAIN
DRE = PAIN *so don’t
Sentinal pile** - skin tag at fissure edge
How will we treat an anal fissure?
Acute: Sitz bath Fiber and Fluid Stool Softeners (ducosate **surfactant) Topical anesthetic - Lidocaine
Chronic
Topical VASODILATOR - Nifedipine, Nitro, Diltiazem
Botulinum Toxin
Surgical
Fissurectomy
Lateral internal Sphincerotomy
Define a perianal abcess
Abscess…. Perianal…..
“Collection of purulent material that arises from GLANDULAR CRYPTS in the anus or rectum”
How will a patient with a Perianal Abscess present?
Severe pain ** not assoc w/ defecation (compare fissure)
Fever* and malaise
What will we find on PE of a perianal abscess pt?
Erythematous, edematous **Fluctuant skin
W/ surrounding induration
*******ALWAYS DO A DRE. You may not immed see the abscess
How do we treat a patient with Perianal Abscess?
Simple - I and D outpatient
Complex - surgical drainage inpatient
Name and describe the complication of a Perianal Abscess
FISTULA in ano
Epitheliazed connective passage from anus or rectume to perirectal skin.
CHRONIC purulent drainage, pruritis, pain
**Needs surgical excision
